Paediatrics: Renal/Urinary/Urology Flashcards
what structures are in the urinary tract ?
- urethra
- Bladder
- Ureters
- Kidneys
What is acute pyelonephritis ? leads to ?
it is when infection affect tissues of the kidney => scarring => reduced kidney function
What 2 things could confirm the diagnosis of pyelonephritis ?
- Temp >38
- Loin pain/tenderness
What is cystitis ?
inflam of the bladder (can be due to infection)
What is the most common cause of UTI ? be specific
most caused by bacterial organism from GI tract
- E.Coli (most common)
Name symptoms of UTI in babies ? (7)
- Fever (often the only symptom)
- lethargy
- Irritabilty
- VOmiting
- Reduced feeding
- Urinary frequency
- Failure to thrive
what investigations would you do for suspected UTI ?
- Clean catch sample
- Microscopy and culture
explain the expected results of a clean catch urine sample for suspected UTI ?
- nitrites
- Leukocytes
describe why there would be nitrites in urine in a UTI ? what causative organism ?
gram -ve bacteria (echericha coli) breakdown nitrates (normally found in urine) to nitrites
urine sample showed negative nitrites and positive leukocytes. What do you do ?
- don’t assume or treat its a UTI
- only leukocytes raised so most likely vulvovaginitis
What do leukocytes in urine suggest ?
can be small amounts normally but rise suggest infection of inflammation
presentation of older infants + children with a UTI ?
- Fever
- Abdo pain
- Vomiting
- Dysuria
- Frequency
- Incontinence
Management of UTI in a baby < 3 months ?
- All children <3months: start immediate IV Abx (ceftriaxone)
- Septic screen (blood cultures, bloods, lactate, consider LP)
Management of UTI in children > 3months ?
- Oral Abx (trimethoprim, nitrofurantoin)
When would you admit a child with UTI ? what would you do ?
- under 3 months
- if septic
- if pyelonephritis
admit + IV Abx
Would investigations would you do for someone with Recurrent UTIs ? to look for what ?
- US scan (I think to look for renal scarring)
- Micturating cysourethrogram (MCUG) (VUR)
What does a micturating cystourethrogram (MCUG) assess ?
assess for vesico-ureteric reflux (VUR)
What is vesico-ureteric reflux (VUR) ? cause of what ?
urine ahs tendancy to flow from the baldderback to the ureterus => upper UTI => renal scarring
- cause of recurrent UTIs
Managmetn of vesicle-ureteric reflux (VUR) ? (2)
- Avoid constipation or excessively full bladder
- Consider prophylactic Abx
What is vulvovaginitis ?
it is inflammation + irritation of the vulva + vagina
In who is vulvovaginitis common ?
common condition affecting girls between 3 - 10 yrs
what is vulvovaginitis caused by ?
caused by sensitive + thinned skin + mucosa around vulva + vagina in young girls
what exacerbates vulvovaginitis ?
- Wet nappies
- Chemical soaps
- Tight clothing (traps sweat)
- Poor toilet hygeine
why does vulvovaginitis affect pre-pubertal girls ?
at puberty: oestrogen helps keep vagina + skin healthy so prevents it
vulvovaginitis presentation ?
- soreness, itching
- erythema
- vaginal discharge
- Dysuria
What would be seen on urine dipstick for vulvovaginitis ?
may show leukocytes nut no nitrites
(don’t misdiagnose as UTI)
vulvovaginitis management ?
- Avoid washing with harsh soaps
- Keep area dry
- Good toilet hygiene
What is nephrotic syndrome ?
It is when the basement membrane in the glomerulus becomes highly permeable to protein => allows protein to leak from blood into urine
classic triad nephrotic syndrome ?
- Low serum albumin
- Raised protein urine content (>3+ on urine dipstick)
- Oedema
other features of nephrotic syndrome ? apart from classic triad
- deranged lip profile
- raised BP
- hypercoagulability
Nephrotic syndrome presentation ? age ?
age 2 - 5
- Frothy urine
- generalised oedema
- Pallor
What is the most common cause of nephrotic syndrome in children ?
minimal change disease
(cause in 90% of children)
What is minimal change disease
nephrotic syndrome without any clear underlying pathology
What will be seen on urinalysis in minimal change disease ? (2)
- small molecular weight proteins
- Hyaline casts
what will be seen on renal biopsy in minimal change disease ?
will not detect any abnormalities
Management of minimal change disease ?
- Corticosteroids (prednisolone)
minimal change disease prognosis ?
most children make a full recovery
Would can cause nephrotic syndrome in children ? (3)
- Minimal change disease (90%)
- Intrinsic kidney disease: focal segmental glomerulosclerosis
- secondary to systemic illness: HSP, diabetes, infection
what are podocytes ?
specialised epithelial ells of the glomerular BM
oedema differential ? (4)
- Nephrotic syndrome
- HF
- Allergic reaction
- Malnutrition
Nephrotic syndrome management ?
- High dose corticosteroids (prednisolone)
- Low salt diet
- Consider dietetics for oedema
- Prophylactic Abx (due to leak of immunoglobulins)
Nephrotic syndrome complications ? (3)
- Hypovolaemia
- Thrombosis
- Infection
explain how nephrotic syndrome could cause hypovolaemia ?
as fluid leaks form intravascular space to interstitial space => oedema and low BP
explain how nephrotic syndrome could cause thrombosis ?
proteins that normally preven clotting are lost though kidneys => low albumin => liver produces prothrombotic proteins => hyper coagulable state
explain how nephrotic syndrome could cause infection ?
kidney leaks immunoglobulins + immunosuppressed by steroid treatment
2-5 year old child with oedema, proteinuria + low albumin. What is the underlying cause ?
nephrotic syndrome due to minimal change disease
What is Henoch-Schonlein Purpura (HSP) ? age ?
It is an IgA vasculitis that presents with a purpuric rash affecting lower limbs + buttock
- in kids <10
what causes the inflammation in HSP ?
inflam occurs in affected organs due to IgA deposits in the blood vessels
what is HSP often triggered by ? (2)
often triggered by upper airway infection of gastroenteritis
HSP presentation: 4 classic features ? how common is each
- Purpura (100%)
- Joint pain (75%)
- Abdo pain (50%)
- kidney impairment (50%)
what causes the purpura in HSP ?
inflam _ leading of blood from small blood vessels
what can the abdo pain in HSP lead to ? (2)
- GI haemorrhage
- Intussception
Describe the kidney impariemtn in HSP ? what does it cause ?
IgA nephritis => haematuria + proteinuria => nephrotic syndrome
causes of a non-blanching rash (5)
- Meningococcal sepsis
- Leukaemia
- HSP
- ITP
- Haemolytic uraemia syndrome
How is HSP diagnosis made ?
- Exclude meningococcal septicaemia + leukaemia
Palpable purpura PLUS: - Diffuse abdo pain
- Arthritis/arthralgia
- IgA deposits on renal histology
- Proteinuria or haematuria
HSP management ?
supportive management with simple analgesia + hydration
What is enuresis ? during day ? night ?
it is involuntary urination
- nocturnal enuresis: bedwetting
- Diurnal enuresis: daytime
When do most children gain continence ? day ? nigh ?
most children get daytime urination control by 2 and nightimte by 3-4 urs
what is primary nocturnal enuresis ?
child has never managed to be consistently dry at night
most common cause of primary nocturnal enuresis ?
variation in normal development
(reassure)
causes of primary nocturnal enuresis ? (6)
- variation in normal dev
- Overactie bladder
- Fluid intake (prior to bed, fizzy drinks)
- Failure to wake up (due to deep sleep + undeveloped bladder signals)
- Psychological stress
- Secdonary causes
describe the behaviour in overactive bladder that causes primary nocturnal enuresis ?
frequent small volume uriantion prevents development of bladder capacity
What secondary causes could cause primary nocturnal enuresis ? (4)
- Chronic constipation
- UTI
- LD
- CP
Management for nocturnal enuresis ?
- Bladder diary
- lifestyle changes (fewer fluids in evening, pee before bed)
- Encouragement + positive reinforcement (no blame + shame or punishment)
- treat underlying cause
- enuresis alarms
- pharmacological treatment
how does an enuresis alarm work ?
device that makes noise at first sign of bed wetting
- need to be used consistently for 3 months
what pharmacoligcla management could be used for nocturnal enuresis ?
- Desmopressin (vasopressin (ADH) analogue): reduce col of urine produced by kidneys
what pharmacological management could be used for overactive bladder ?
- oxybutinin (anticholinergic): decrease contractility of bladder
What is secondary nocturnal enuresis ? more indicate of what ?
child starts wetting bed after being dry for 6 months
- more indicitat of an underlying illness
what could cause sedentary nocturnal enuresis ?
- UTI
- Constipation
- T1DM
- Psychosocial problems
- maltreatment
what 2 types of diurnal enuresis is there ?
- Urge incontinence (overactive bladder)
- Stress incontinence
What is Wilms tumour ? what age group ?
it is a tumour that affects the kidneys in children <5yrs
wilms tumour presentation ?
- parents may comment on amass in the Childs abdo
- abdo pain
- haematruia
- Lethargy
- Hypertension
- Weight loss
investigations for Wilms tumour ? diagnostic ?
- US-KUB
- CT or MRI: to stage the tumour
- Biopsy to identify the histology (definitive diagnosis)
how is Wilms tumour managed ?
- Surgical excision: of the tumour and the affected kidney
- Adjuvant chemo + radiotherapy
What is another term for undescended testes ?
cryptochiadism
what is cryptochiadism ?
undescended testes
- congenital acscne of one or both testes in the scrotum (failure of descent into the scrotum)
when and how should the testes usually descend ?
in utero: normally the testes develop in the abode and then gradually migrate down through inguinal canal => scrotum (prior to birth)
what are ectopic testes ?
testis is present but not found along the normal pathway of descent
what can undescended testes lead to if unresolved ?
higher risk of
- testicular torsion
- Infertility
- testicular cancer
undescended testes RF ? (4)
- FHx of undescended testicles
- Low birth weight, SGA
- Premature
- maternal smoking
Undescended testes management ? when should you do something ?
cryptochiadism
- usually will descend in 3-6 months
- 6-12 months: surgical correction (orchidopexy)
What is hypospadias ?
It is a congenital condition affecting males, where the urethral meatus (urethral opening) is abnormally displaced to the under side of the penis
how common is hypospadias ?
around 1/300 births (male)
describe some of the features of hypospadias ?
- ventral opening of urethral meatus
- Ventral curvature of penis (cordee)
- Dorsal hooded foreskin
Hypospadias management ? how urgent? do not do what ?
- Referral to paediatrics specialist
- Do not circumsize
- Surgery after 3-4 months age (to correct positions of meatus)
Complications of hypospadias ? (3)
- Difficulty direction urination
- Cosmetic/psychological
- Sexual dysfunction
What is hydrocele ? what structure involved ?
it is a collection of fluid within the tunica vaginilis that surrounds the testes ?
What is a simple hydrocele ?
fluid is trapped in the tunica vaginalis + gets reabsorbed over time
what is a communicating hydrocele ?
tunica vaginalsis connected to peritoneal cavity => hydrocele fluctuates in size
hydrocele most common presentation ?
- Painless scrotal enlargement
hydrocele examination ? (response to light)
it would transilluminate with light
differential for scrotal or inguinal swelling ?
- Hydrocele
- Partially descended testes
- Inguinal hernia
- testicular torsion
Hydrocele management ?
- Simple hydrocele: usually resolve alone
- Communicating: Surgical (in children >2yrs)
What is testicular torsion ? what structures involved ?
It is twisting of the spermatic cord with rotting of the testicle (Surgical emergency)
What can testicular torsion lead to ? (complications)
delay => increase risk of ischaemia + necrosis of testicle => subfertility + infertility
testicular torsion presentation ?
teen patient playing sport
- Acute unilateral tisticular pain
- abdo pain
- N&V
What could be found on examination of a patient with testicular torsion ?
- Firm swollen testicle
- Absent cremesteric reflex
- Rotation (epididymis not in normal location)
Testicular torsion investigations ? diagnostic ?
- Clinical diagnosis - can go strain to surgery if suspected
- If unsure: scrotal US
testicular torsion management ? how quick does it need to be done ?
uro-emergency: urgent treatment within 4-6 hrs
- nil by mouth, analgesia
- Surgery: orchiopexy (correct position), orchidectomy (remove testicle)
What is paraphemosis ? what does this lead to ?
It is the inability to pull forward a retracted foreskin over the glans penis => glans becomes increasingly oedematous (due to reduce venous return) => vascular engorgment of distal penis + further oedema
what is phimosis ?
reverse of paraphimosis: cannot retract the foreskin over the glans
what happens if paraphimosis is untreated ?
ischaemia + worsening infection => necrosis
paraphimosis management:
- Analgesia
- Dextrose soaked gauze (osmotic effect => reduce oedema) plus manual pressure
A 4 month old girl presents with a culture-proven E. coli UTI. She is treated with oral antibiotics, and responds well to treatment within 48 hours. What, if any, imaging is required in this case?
Ultrasound scan within 6 weeks
In a 9 month old girl with presenting with UTI, when would a micturating cystourethogram be appropriate?
MCUG is not normally appropriate in this group
(appropriate from 12 months onwards)
A child had repeated episodes of UTI as a child. What is the best method to investigate for renal scarring?
DMSA scan
